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Postgastrectomy Gastric Cancer Patients Are at High Risk for Colorectal Neoplasia: a Case Control Study

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Postgastrectomy Gastric Cancer Patients Are at High Risk for Colorectal Neoplasia: a Case Control Study ORIGINAL ARTICLE pISSN 1598-9100 • eISSN 2288-1956 https://doi.org/10.5217/ir.2020.00009 Intest Res 2021;19(2):239-246 Postgastrectomy gastric cancer patients are at high risk for colorectal neoplasia: a case control study Tae-Geun Gweon1*, Kyu-Tae Yoon1*, Chang Hyun Kim2, Jin-Jo Kim2 1Division of Gastroenterology, Department of Internal Medicine and 2Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea Background/Aims: Several studies have shown that colorectal neoplasms (CRN) including colorectal cancer (CRC) may be prevalent in patients with gastric cancer. However, in most of these studies, colonoscopy to investigate the prevalence of CRN was performed prior to surgery. We aimed to investigate whether CRN was more prevalent in postgastrectomy gastric cancer patients than in healthy individuals. Methods: We reviewed the medical records of those patients within a cohort of gastric can- cer patients with gastrectomy who underwent colonoscopy between 2016 and 2017. Controls age- and sex-matched with gas- tric cancer patients at a 2:1 ratio were identified among those who underwent colonoscopy at a health-promotion center. The frequencies of CRN, advanced CRN (ACRN), and CRC among patients with gastrectomy were compared with those in the con- trol subjects. A total of 744 individuals (gastric cancer, 248; control, 496) were included. Results: The rates of CRN and ACRN in the gastric cancer group were higher than those in the healthy individuals (CRN, 47.6% vs. 34.7%, P<0.001; ACRN, 16.9% vs. 10.9%, P=0.020). The rate of CRC was comparable between the 2 groups (2.0% vs. 0.6%,P =0.125). Multivariate analysis identi- fied previous gastrectomy for gastric cancer and male sex as significant risk factors for (A)CRN. Conclusions: CRN and ACRN were more prevalent in patients who underwent surgery for gastric cancer than in the control group. Regular surveillance colo- noscopy at appropriate intervals is indicated after gastrectomy. (Intest Res 2021;19:239-246) Key Words: Stomach neoplasms; Colonoscopy; Colorectal neoplasm; Colonoscopic surveillance INTRODUCTION doscopic treatment in gastric cancer patients was reported as 1%–4%.3-6 Although the prevalence of colorectal neoplasms The prognosis of patients with gastric cancer has improved (CRN) including CRC was higher in patients with gastric can- with detection at early stages and advances in treatment mo- cer than in healthy individuals, most studies have investigated dalities.1,2 Therefore, detection of secondary cancer is as im- the prevalence of concomitant CRN at the time of surgical re- portant as surveillance of gastric cancer recurrence. Colorec- section or endoscopic resection of gastric cancer. CRC devel- tal cancer (CRC) has been recognized as the most common ops from benign CRN through the adenoma-carcinoma se- synchronous malignancy in patients with gastric cancer.3-5 The quence.7 Regular surveillance colonoscopy based on the num- prevalence of concomitant CRC at the time of surgical or en- ber and histology of resected CRN is recommended after re- section of CRN.8,9 No previous study has investigated the prev- Received March 9, 2020. Revised May 21, 2020. Accepted June 3, 2020. alence of CRN after surgical treatment of gastric cancer. In this Correspondence to Chang Hyun Kim, Department of Surgery, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 56 study, we aimed to investigate whether CRN was more preva- Dongsu-ro, Bupyeong-gu, Incheon 21431, Korea. Tel: +82-32-280-5052, lent in gastric cancer patients after surgical treatment than in Fax: +82-32-280-5987, E-mail: [email protected] healthy individuals. *These authors contributed equally to this study. This study was presented as an oral poster at IMKASID on April 13-14, 2018, in Seoul, Korea. © Copyright 2021. Korean Association for the Study of Intestinal Diseases. All rights reserved. 239 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Silvio Danese, et al. • iSTART consensus recommendations Tae-Geun Gweon, et al. • Colonoscopy after gastrectomy METHODS plastic lesions (hyperplastic, lymphoid, inflammatory). Ad- vanced CRN (ACRN) was defined when one of the following Among a cohort of gastric adenocarcinoma patients who un- criteria was met: (1) adenocarcinoma; (2) adenoma sized at derwent gastrectomy at Incheon St. Mary’s Hospital (Incheon, least 1 cm; (3) the presence of at least 3 adenomas; and (4) the Republic of Korea), we reviewed the medical records of con- presence of villous adenoma or high-grade dysplasia.8,20 The secutive subjects who underwent colonoscopy between Janu- rate of CRN, ACRN, and CRC and the number of adenomas ary 2016 and December 2017.10 We excluded patients with ce- per patient were analyzed. The protocol of this study was ap- cal intubation failure; or inadequate bowel preparation. Colo- proved by the Institutional Review Board of Incheon St. Mary’s noscopy was performed at least 1 year after gastrectomy. In Hospital (IRB No. OC17MES0031). Written informed consent our center, colonoscopy for gastric cancer patients is included was obtained from all patients. in the routine staging work-up before surgery.11 Therefore, most gastric cancer patients undergo colonoscopy before surgery. 3. Statistical Analysis The control group comprised healthy subjects who underwent All statistical analyses were performed using IBM SPSS ver- colonoscopy at the health-care center of our institution during sion 20 (IBM Corp., Armonk, NY, USA). Continuous variables the study period and were matched with gastric cancer patients were compared using Student t-test or the Mann-Whitney test by age and sex in a 2:1 ratio. Demographic characteristics, bow- when appropriate. Categorical variables are presented as el preparation quality, and results of colonoscopy were inves- number (percent) and compared using the chi-square or Fish- tigated. Cancer staging and type of surgery were investigated er exact tests. We compared the clinical data and prevalence in the gastric cancer group. Cancer staging was performed at of (A)CRN and CRC between the gastric cancer and the con- the time of gastrectomy using the 7th edition of the American trol group. To investigate the factors contributing to having (A) Joint Committee on Cancer Staging Manual.12 CRN or CRC, we compared the clinical data of all the patients with and without (A)CRN or CRC. Logistic regression model- 1. Colonoscopic Examinations ing was used to perform multivariate analysis of risk factors Colonoscopy was performed by 3 attending physicians with for (A)CRN or CRC that were found to be significant in the uni- more than 4 years of experience using an Olympus (Olympus, variate analysis. Odds ratio (OR) and 95% confidence interval Seoul, Korea) series Q260 or Q290 colonoscope.13,14 Bowel (CI) were calculated for the prevalence of (A)CRN and CRC. preparation was done with 4 L of polyethylene glycol. To ob- A P-value <0.05 was considered significant. tain optimal bowel cleansing, patients were instructed to in- gest additional liquid until no solid particles were observed in RESULTS the bowel effluent.15 Bowel cleansing quality was assessed us- ing the Aronchick scale.16,17 Polyp resection was performed Two hundred and sixty-six patients with gastric cancer under- during withdrawal of the colonoscope. The colonoscopists went colonoscopy during the study period. Of these patients, were encouraged to observe the colonic mucosa for at least 6 18 were excluded because of cecal intubation failure (n=5) or minutes.18 Polyp resection was performed by cold snare pol- inadequate bowel preparation (n=13). After matching of heal- ypectomy or conventional endoscopic mucosal resection at thy subjects, a total of 744 patients were finally included in this the physician’s discretion. Histologic assessment of resected study: gastric cancer (n=248) and healthy control (n=496). polyps was performed by specialist gastrointestinal patholo- The demographic and clinical data of the 2 groups are shown gists. Cecal intubation time, colonoscope withdrawal time, and in Table 1. Age, sex, comorbidities, family history of CRC, and total colonoscopy time were analyzed. Colonoscope withdraw- factors related to previous colonoscopy were similar between al time was determined as the time difference between photo- the 2 groups. Body mass index was lower in the patients with graphic documentation of the cecum and anus in patients gastrectomy (gastric cancer group 21.3 kg/m2 vs. control group who did not undergo any procedures such as a biopsy or pol- 24.4 kg/m2, P<0.001). Indications for colonoscopy differed be- ypectomy.19 tween the 2 groups (P<0.001). The median interval between surgery and colonoscopy in the gastric cancer group was 51 2. Definition months. CRN included adenomas or cancers but excluded nonneo- 240 www.irjournal.org <doi> • <doi 1> https://doi.org/10.5217/ir.2020.00009 • Intest Res 2021;19(2):239-246 Table 1. Baseline Characteristics Characteristics Gastric cancer (n=248) Control (n=496) P-value Age (yr) 62.4±8.5 62.4±8.5 1.000 Male sex 148 (60.0) 296 (60.0) 1.000 Body mass index (kg/m2) 21.3±2.2 24.4±3.2 <0.001 Comorbidity Diabetes 47 (19.0) 105 (20.2) 0.479 Hypertension 55 (22.2) 92 (18.5) 0.241 Constipation 15 (6.0) 25 (5.0) 0.566 Family history
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